The Migraine Girl offers…Tired of Being Tired. "Lately I've felt inexplicably sleepy all my waking hours. What could be going on?" andURGENT: A Petition. A proposed law which would require the use of fluorescent lights - one of the most common triggers for migraines – instead of (non-pain-inducing) incandescent bulbs is discussed.

I am flattered and embarassed by all the recent attention to my "Last Lecture." I am told that, including abridged versions, over six million people have viewed the lecture online. The lecture really was for my kids, but if others are finding value in it, that is wonderful. But rest assured; I'm hardly unique. Send your kids to Carnegie Mellon and the other professors here will teach them valuable life lessons long after I'm gone.

Wednesday, May 21, 2008

Body's natural painkillers may damp down phobias

The way humans are conditioned by fearful stimuli is to some extent damped down by the body's own pain-relief system, a study suggests. The finding may shine light on the neural mechanisms behind anxieties, phobias and even post-traumatic stress disorder.

Scientists have known for a long time that if you pair an innocuous stimulus (such as a tone) with something aversive (such as a shock to the feet), animals, including humans, will learn to show a "conditioned fear" response.

With repetition, the innocuous stimulus alone brings on the fear response. Both the learning and the initiation of this response take place in a part of the brain known as the amygdala.

One of the more perplexing features of the conditioned fear response is that, when the dreaded stimulus is something painful, people actually tend to experience less pain the more they are exposed to it.

Work in rodents has revealed that this is because opioids – chemicals that have a morphine-like effect on the body – are called into operation during the conditioning and they end up blunting the pain. Blocking the opioids not only stops the pain from being lessened, but also intensifies the learning process.

Thirty male volunteers were asked to watch green triangles and blue pentagons on a screen inside an MRI scanner. One of the symbols was followed half the time by a moderately painful application of heat to the forearm; the other was never followed by pain.

Half the volunteers were infused with naloxone, a drug that blocks the effects of opioids, while the others got saline solution as a control. The researchers were blind as to which group was getting what treatment.

The brain scans showed that in people whose opioid systems had been blocked, the amygdala showed a fear response that did not diminish with exposure. Every time they saw the symbol associated with pain, their amygdalas reacted strongly. In the control group, however, the activation decreased over the course of the experiment.

Because the group receiving naloxone was reacting more fearfully, the researchers speculate, they were learning the association more intensively.

The team also found behavioural evidence that this might be the case. At the beginning of each trial, volunteers had to perform a reaction time task – pressing a button to indicate on which half of the screen the symbol had appeared.

Overall, subjects reacted more quickly to the cue signalling pain than the cue signalling nothing – but the opioid-free subjects reacted significantly faster.

"This natural response advantage to something dangerous was much stronger in the people who received naloxone," says Eippert.

The researchers speculate that opioid deficiency could be a contributing factor to anxiety disorders and exaggerated fear responses. Knock-out mice whose opioid systems have been genetically "switched off" do seem to be prone to anxieties and exaggerated conditioned fear responses, points out Eippert.

"It potentially has far reaching implications," says Jon-Kar Zubieta at the University of Michigan in Ann Arbor, US. There is tremendous variability in how individuals respond to threats and stress, he says, which is thought to relate to the risk developing anxiety disorders.

"This study examines the circuits and neurochemical systems that are likely to underlie that response heterogeneity." The research could help open new avenues for understanding, preventing and treating these types of illnesses, he says.

It was the first day of Meier's internship at a hospital in Portland Oregon, and after being assigned 23 patients, she was suddenly told that one of her patients, who had been in the Intensive Care Unit for months, was "coding." She raced to the ICU where the resident told her to put in a "central line."

"Everyone just walked out of the room," she remembers. I stood there. I still sometimes flash back on that scene: the patient, naked, lying on the table, strips of paper everywhere, the room empty. This was my patient. I felt I was supposed to do something -- but I didn't know what."

Meier left the room and, in the hallway, saw the patient's wife. "I walked right past her," she recalls, nearly shuddering at her own cowardice. I didn't know what to say. I didn't even say 'I'm sorry.' As a physician, I didn't think that I was supposed to do that. "

I heard Dr. Diane Meier tell this story at a conference for medical students at Manhattan's Mt. Sinai School of Medicine last week. When she finished, she asked her audience, "What is the hidden curriculum here? What does this story tell you?'

Meier drew a third lesson: "Before he died, this patient had spent two months in the ICU. We had done everything possible to prolong the dying process." As a doctor, you have to step back and say, 'What is this experience telling me, and is this right?'"

As a palliative care specialist, Meier spends much of her time with dying patients. For many, "palliative care" offers a middle road between pulling out all the stops and simply giving up hope. Like traditional "hospice" care, palliative care focuses on "comfort" rather than "cure," emphasizing pain management and easing the emotional trauma of facing death, both for the patient and for the family. But palliative care also includes procedures aimed at treating the symptoms of the disease.

In the past, Meier explains, physicians have seen caring for a terminally ill patient as an "either/or" situation: "Either we are doing everything possible to try to prolong your life -- or when there is 'nothing more that we can do,' only then do we make the switch to providing comfort measures. This dichotomous notion -- that you can do one thing alone and then the other thing alone later -- has nothing to do with the reality of what patients and their families go through."

In her talk last week, Meier explained that her first patient was one of three who marked turning points on her life as a physician. Originally, she trained to become a geriatrician, a doctor who cares for people over 65. "I think because I was very close to my grandfather," she explained, "and because I'm a 'lumper' not a 'splitter'," she added, referring to the distinction between doctors who prefer to treat the whole patient, head to toe, and those who prefer to specialize in a body part: the foot, for example, or the eye.'

Her interest in treating the elderly brought her to Mt. Sinai, which, at the time, had the only Department of Geriatrics in the country. But as her career unfolded, she found herself "become more and more alienated from medicine. Here, in the hospital, everyone was running around, ostensibly trying to help the patient, but actually often hurting the patient. I thought about quitting. I had a fantasy of opening a bakery/book shop where I could read and eat brownies ..." she told the med students.

"Then I met a patient I will call Mr. Santanaya."

Meier first encountered Santanaya when she was walking down a hospital hallway and heard a man screaming and moaning in pain. She looked into his room and there he was, pinioned to his bed, hand and foot, in "four-point restraint."

"I went to the nurse and asked, 'Why is this man in a four-point restraint?" The nurse called for the intern.

"I'll never forget this kid's face," Meier recalled "To me, he looked about twelve years old. And terrified.

Meier asked the question again, and the intern explained: "He has lung cancer that spread to his brain and he's delirious. We put a feeding tube up into his nose and down to his stomach, and he pulled it out. So we tied his hands. Then he pulled it out with his knees and feet -- so we tied his knees and feet."

"The feeding tube is very uncomfortable," Meier told the students. "It makes the nose and esophagus raw. I asked the intern, 'Why do we have to do this?'"

"He looked at me with tremendous distress in his eyes: 'Because if we don't, he'll die."

"I realized he didn't know any better," said Meier. "Neither did the resident or the attending physician. I realized that this was an educational problem.

"They cared about the patient. This wasn't callousness or indifference or venality. They just didn't know when too much is too little." So Mr. Santayana spent 33 days tied hand and foot to his bed before he died. He spoke no English, but during that time, he kept screaming "Ayudeme! Ayudeme!" (Help Me! Help Me!)

Why didn't Mr. Santayana's physician intervene to do something to help him? "He didn't have a primary care physician because he was on Medicaid," Meier explained. So it was left to the hospital staff, and not knowing what else to do, they simply followed procedure.

"This was the early 1990s, and that is when I decided to shift my career to try to make up for what happened to Mr. Santayana," said Meier. Then she got lucky.

Dr. Robert Butler, founder of gerontology at Mount Sinai, and a friend of George Soros, urged her to apply for funding from Soros's newly formed Project on Death in America. Meier and three colleagues won the funding and in 1995, with help from Soros and the United Hospital Fund, launched the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine. The Robert Wood Johnson Foundation also invested in developing content. In 1999 Meier and Dr. Christine Cassel founded the Center to Advance Palliative Care (CAPC) . As a result of CAPC's program, by 2005, the number of hospital-based palliative care programs in the U.S. had roughly doubled to 1,240, and some 3,100 health care professionals had been taught CAPC's methods and ethics.

The third patient who Meier told the students about last week is a 24-year-old who she called "Kate." Kate had just graduated from college and had worked and saved enough money to go to Australia. There she developed the worst headache of her life. "She called her mother from Sydney and her mother came to get her," Meier told her audience. "In retrospect, she might have been better off if she had stayed in Australia."

The problem was that Kate had no health insurance. She was only 24 and she thought she didn't need insurance.

Her mother brought her directly from the airport to Mt. Sinai, "where she was admitted directly to the oncology service, not to a doctor," Meier explains. Like Mr. Santayana, she would be on Medicaid and so wouldn't have her own doctor. Kate was diagnosed with leukemia.

"I met Kate on day 7 when a consult called me to say that they had a manipulative drug-seeking patient with acute myeloid leukemia," Meier recalled. "By then, Kate had earned the contempt and hostility of the house staff because she was constantly screaming for pain-killers.

"It turned out that no one knew the half-life of the opiate they were giving her -- not the attending physician, not the resident, not the intern."

Meier then turned to her audience, made up largely of second-year medical students. "Does anyone here know the half-life," she asked, naming the pain-killer.

No one did. (The half-life of a pain-killer tells you how long it will be before it wears off.)

"What they were giving her provided relief for only 90 minutes," said Meier, "and they were giving it to her every six hours." After 90 minutes , Kate would begin ringing for nurse. Then, after a half hour, when no one came, she would begin ringing more and more frantically, and finally begin screaming. "Between four and six hours, she would just be screaming," said Meier.

This had been going on for seven days. "The pain specialists wouldn't see her because she had no insurance."

"I doubled the dose and ordered that it be given to Kate every three hours, around the clock," said Meyer. "And before long, she was transformed into the sweet, charming intelligent person she always had been."

"Kate had become the victim of iatrogenic pseudo-addiction," Meier added. She wasn't an addict, but she was behaving like an addict and seemed like an addict -- a pseudo-addiction created by her doctors, which makes it an "iatrogenic disease," an illness caused, inadvertently, by medical care.

Why hadn't her mother tried to persuade the doctors to give her more pain-killers? "Kate was the middle child in an Irish family of seven kids and one of her brothers had become addicted to drugs. As a result, the mother was terrified of opiates," said Meier. "The palliative care team had to spend time with the parent, explaining that pain kills.

The only possible hope for Kate was a bone marrow transplant. Because she was on Medicaid, this would be very hard to get. "It took six weeks of begging to get someone to take her," Meier recalled. "And then the transplant failed.

"While she was dying, Kate told us that the worst part of the experience had been those first six days when she was labeled a 'manipulative drug addict.' She was marginalized because her doctors did not know how to administer the opiates.

"Untreated pain is a medical emergency," Meier told the students. "The reason no one here knew the half-life of that opiate is because learning about pain-killers is not a priority in medical curriculums." In fairness, this is the sort of thing that doctors on the ward often look up. But in this case, no one even tried to look it up.

"The relief of suffering is a fundamental part of medicine," Meier concluded. "In this country there is a tremendous amount of stigma associated with opiates. When you are caring for patients, and you leave an order for the nurse to administer the pain-killers, remember, there's a real chance that she'll think, 'This is dangerous. I don't want something bad to happen on my shift. Okay, I'll give it to you -- but I won't give you enough.'

"This is why pain is so poorly managed in this country."

In Italy, by contrast, a patient dying of cancer is often sent home, with morphine, to die in his own bed. His wife administers the morphine and she is given enough to keep him as much as he wants -- when he wants it. In the U.K., where hospice care was invented in the 1960s, there are many more palliative care specialists than in the U.S.

Here, medicine is all about "cure," not about "care." "Defeating death at any cost: that is the priority," Meier told me. "It comes ahead of reducing suffering or considering the quality of the patient's life. If you look at NIH funding," she pointed out, "you see that this is where the money goes -- to cure cancer, to prevent all heart disease and stroke."

This is not to say that Meier favors cutting back on end-of-life care because it is so expensive and so much money is "squandered" during the final year of a patient's life. "The problem is, of course, that we don't know who is in their last year -- or their final three months," Meier observed. "The fact that we spend so much on these patients in their final months of life is not necessarily a bad thing," she added. "These are the sickest people in the hospital, who need the most care. We shouldn't say: 'We're wasting money on the dying.' But," she added , "we should be asking, 'Is this the best care? Is it appropriate care?"

Clearly, we need more palliative care specialists like Meier. But this is another case where we don't pay enough for "thinking medicine" -- which involves talking to and listening to the patient -- rather than cutting him or radiating him.

"When a three-person palliative care team made up of a doctor, a nurse and a psychologist spends 90 minutes in a meeting with a family, Medicare would probably pay $130 to $140 -- for all three people," Meier told me. "And Medicare is one of the better payers. This explains why Meier earns $100 for every several thousand dollars that her husband, an invasive cardiologist, takes home. "Though," Meier said mildly, "it would be hard to say that one of us is practicing more sophisticated medicine."

Wednesday, May 14, 2008

This curriculum has been designed to improve patient outcomes globally by providing clinically relevant postgraduate education in the sciences, concepts, and procedures for pain management within the context of today's multidisciplinary patient care team, and is based on the Core Curriculum for Professional Education in Pain created by the International Association for the Study of Pain's Task Force on Professional Education in Pain.

Tuesday, May 13, 2008

Interventional Procedures Now Included In American Pain Society's Low Back Guideline

12 May 2008

For low-back pain patients and their doctors, the American Pain Society, http://www.ampainsoc.org/, said it is expanding its evidence-based, clinical practice guideline on diagnosis and treatment of chronic low back pain to include recommendations on surgery and other interventional treatments. The expanded guideline was previewed in a symposium at the APS Annual Scientific Meeting.

The second part of the APS guideline is based on a multidisciplinary panel's review and analysis of volumes of evidence related to diagnosis and treatment of low-back pain with a number of interventional procedures and surgeries, according to Roger Chou, MD, director of the American Pain Society's Clinical Practice Guideline Program and associate professor of internal medicine, Oregon Health & Science University.

Chou noted that in addition to the multidisciplinary panel that formulated the guideline for evaluation and management of low back pain in primary care settings, additional experts with expertise on interventional therapies and surgeries for low back pain were recruited to review the evidence and formulate the expanded recommendations.

"Prior to finalizing the guideline, APS conducts extensive peer review, and has sent the guideline to more than 20 experts in surgery, interventional pain medicine, primary care, and other disciplines for comments and feedback," Chou said.

Low-back pain is the fifth most common reason for doctor's office visits and one in four adults report having it last a least a day. Annually, low-back pain is estimated to account for more than $26 billion in direct health care costs in the U.S.

"The evidence is much better than even five or 10 years ago and both the primary care and interventional recommendations will help physicians be more confident when evaluating possible therapies for low back pain," said Chou. "As always, physicians and patients should discuss possible options proven by the evidence and choose the ones that make sense for their situation," he added.

During the symposium, Chou and two panel co-chairs, Richard Rosenquist, MD, assistant professor of anesthesiology, University of Iowa, and John Loeser, MD, professor, Department of Neurological Surgery, University of Washington, reported that for many interventional procedures the evidence from randomized controlled trials is mixed, sparse, not available or showed no benefits. Accordingly, the expanded, evidence-based APS guideline will report:

Invasive diagnostics, such as provocative discography, facet joint block and sacroliliac joint block tests, have not been proven to be accurate for diagnosing various spinal conditions, and their ability to effectively guide therapeutic choices and improve ultimate patient outcomes is uncertain.

Surgery to treat radiculopathy and spinal stenosis is effective, though the benefits diminish over time.

Effectiveness of surgery for non-radicular low back pain is less certain, with some studies showing no benefits compared to intensive interdisciplinary rehabilitation. In addition, a significant proportion of patients experience suboptimal outcomes including persistent pain or functional deficits following surgery.

The expert panel reaffirms its previous recommendation that all low-back pain patients stay active and talk honestly with their physicians about self care and other interventions. "In general, non-invasive therapies supported by evidence showing benefits should be tried before considering interventional therapies or surgery," said Chou.

Recommendations from the first APS Clinical Practice Guideline on Low Back Pain were intended for primary care physicians and appeared in the Oct, 2, 2007 issue of the Annals of Internal Medicine. For diagnosis, the first APS low-back pain guideline advises clinicians to minimize routine use of x-rays or other diagnostic tests except for patients known or believed to have underlying neurological or spinal disorders.

In addressing treatment options, it recommended that medications used should be appropriate for the severity of baseline pain and functional impairment, and clinicians should weigh carefully potential benefits and risks of any drug and explain them. Also for various non-pharmacological treatments supported by the evidence, from spinal manipulation to massage therapy, the first guideline panel recommended they be considered for patients who do not improve with self-care options and prefer not to take pain medications.

The International Association for Pain and Chemical Dependency is an international organization dedicated to promoting appropriate and effective treatment for all patients with pain, including individuals with substance abuse, mental health or other co-occurring problems that may make treatment more challenging. The association encourages cooperation among professionals in the fields of health care, policy and regulation, law enforcement, law, politics and the media to improve communication and education for the appropriate use of controlled substances in pain treatment.

The 8th International Conference on Pain and Chemical Dependency (ICPCD) will be held October 29 – November 1, 2008 at the Loews Philadelphia Hotel in Philadelphia, PA.

ICPCD, the conference, has been held seven times over the past 10 years. Attendees returned year after year to meet and learn with others involved in managing care at the interface of pain and chemical dependency – and it was around these convocations that an international community of practitioners formed. Over time, that community organized, establishing the International Association for Pain and Chemical Dependency (IAPCD), the association. Now, appropriately, the ICPCD is the annual meeting of the rapidly growing IAPCD.

I'm a 28-year-old writer and college writing instructor trying to balance multiple chronic illnesses (PCD, bronchiectasis, celiac disease, etc) with, you know, the rest of my life. My book, Life Disrupted: Getting Real About Chronic Illness in Your Twenties and Thirties (Walker), will be in bookstores June 24 and is available for pre-order now.

Davis, CA: Cannabis significantly reduces neuropathic pain compared to placebo and is well tolerated by patients with chronic pain conditions, according to clinical trial data to be published in The Journal of Pain.

Investigators at the University of California at Davis, in conjunction with the University of California Center for Medical Cannabis Research (CMCR), assessed the efficacy of inhaled cannabis on pain intensity among 38 patients with central and/or peripheral neuropathic pain in a randomized, placebo-controlled, crossover trial.

They concluded: "In the present experiment, cannabis reduced pain intensity and unpleasantness equally. Thus, as with opioids, cannabis does not rely on a relaxing or tranquilizing effect, but rather reduces both the core component of nociception (nerve pain) and the emotional aspect of the pain experience to an equal degree."

The study is the second clinical trial conducted by CMCR investigators to conclude that inhaled cannabis significantly reduces chronic neuropathy, a condition that is typically unresponsive to both opioids and non-steroidal anti-inflammatory drugs such as ibuprofen.

Commenting on the study's the findings, NORML Deputy Director Paul Armentano said: "With the results of each published study it becomes increasingly apparent why the US government has tried consistently to stonewall clinical research on the therapeutic effects of inhaled cannabis. Each new trial the Feds approve provides additional evidence undermining the government's 'flat Earth' position that cannabis is without medical value."

SACRAMENTO, Calif. — Words failed Mark Collen when his doctor had asked about his chronic pain. Strange, because Collen had always been such a talkative guy.

But all the descriptive terms tossed out during that memorable 1997 appointment — "searing, stabbing, burning, numbing, pins-and-needles" — could not fully express Collen's sciatic nerve pain, vicelike and unrelenting.

And when the doctor asked where the pain fell on a standard 0-to-10 pain scale, Collen wondered: How could a mere number quantify the unbearable?

What was needed, he felt, was a tangible expression of his inner turmoil. Maybe then his doctor would understand. Maybe then, several years after two surgeries, he might be prescribed the right amount of painkillers needed to live and function normally.

Chronic pain, indeed, had taken away much of the joy from Collen's life. His marriage had ended. His career as a salesman for a major insurance company had ended. His hope of living pain-free had ended, as well. (He declines to discuss whether he is on disability, saying only "I get by.")

"Half the time," Collen recalls, "I was lying in pain on my futon, going over how many ways I could kill myself."

What he did gain from the ordeal, eventually, was an artistic outlet. Having never taken an art class, Collen nonetheless created a stark mixed-media piece featuring a photo of himself entombed in packing tape, except for a single eyeball, and a poem about suicide.

He showed it to the doctor on his next visit.

"I could see her eyes welling up," Collen says. "She understood. That did it. There was never a question in my pain doctor's mind after that."

That first foray into art as therapy has since led the 47-year-old Sacramento, Calif., man to create a not-for-profit online gallery,

www.painexhibit.com, in which he solicits images of work from others who are chronic pain sufferers.

In the 10 years since he's started the project, Collen has received more than 500 examples from around the world — many poignant, all pointed and, frankly, painful to see.

The site recently was featured in The New York Times, and the artwork has appeared each quarter on the cover of the Journal of Pain & Palliative Care Pharmacotherapy. Collen, who has become an outspoken advocate for non-malignant chronic pain patients, also has had essays and writings appear in medical journals such as The Pain Practitioner and Practical Pain Management.

Reviewing the exhibit, Dr. William M. Lamers wrote that "the gap between our scientific understanding of how to treat pain and the clinical application of that knowledge remains one of the frustrations of modern health care. ... The Pain Exhibit is a plea for understanding and better care for those who suffer."

At the very least, says Penney Cowan, founder of the American Chronic Pain Association, it will start a dialogue. Cowan says the Pain Exhibit was featured at a convention for pain-management health-care providers.

"It's a wonderful way of communicating how we feel," Cowan says. "It's not about how well you paint or sculpt. It's how you interpret your pain."

Collen's painful feelings began in 1995, eight days after his 35th birthday. At work, he was bending over to put a cardboard box in the back seat of his car when he felt immediate pain. Turns out, he had herniated a disk, and pain radiated down his left leg.

Then came the surgeries: one to remove a portion of the bone around the disk, another to relieve scar tissue pressing on his nerve. Neither, he says, significantly helped ease the pain.

"It's unpredictable," he says. "Sometimes, I'll be laying in bed reading, and all of sudden it's unbearable. (But) there is always some level of pain."

Collen does not deny that some patients taking opioids will go to doctors to, as a common phrase among clinicians goes, "shop for meds." But he believes many physicians overreact and under-treat.

"They're afraid to prescribe," he says. "One (reason) is the DEA (Drug Enforcement Agency) has prosecuted doctors — not a lot but enough to scare them. And the second is addiction.

"But there's a big difference between physical dependence and emotional addiction. Say you've never used drugs in your life and, after you get injured, you're prescribed opioids. What will happen when you stop using it is the body will have withdrawals. That's physical dependence. Emotion addiction is, 'I want that drug!' "

Collen has used his own experience as a jumping-off point to research topics such as pain tolerance — defined by the American Academy of Pain Medicine as "decreasing relief of pain with the same dosage over time."

That led to a 2007 essay he wrote, published in the Journal of Pain & Palliative Care Pharmacotherapy, in which he posits that patients become afraid of their pain doctors and don't adequately express the level of their pain.

"Fear of losing the prescription may encourage patients not to mention that their medication is no longer working," he writes.

Some of the images are startling in their depiction of pain in its numerous manifestations.

In "Resonance," Susan Gofstein of Chicago painted a self-portrait of herself on her MRI film, minus most of her face, to illustrate her chronic facial pain. Helen Tupper of Dartmouth, Canada, expressed her chronic muscle spasms by visualizing it as a "hot fiery ball of pulsating pain, which is wrapped up in barbed wired."

Collen has several of his own pieces included. One is a plaster likeness of a foot with a dozen steel blades piercing the sole. Another, titled "Hey Doc, Have You Figured It Out Yet?," is a 10-foot- high tower of X-rays, which Collen says represents doctors ordering "the same test over and over again in hopes of understanding the cause of chronic pain."

By far the most visceral is "Trapped in Hell." A red plaster face, a rictus of pain, is impaled by three strips of rebar.

Though the visual is arresting in itself, Collen's statement about the piece is pretty illustrative, as well:

"There are times when my pain medication stops working and the horrible nerve pain takes over, ripping through my innocent leg. I lay on my bed trapped, trapped by pain. I feel fear, afraid the pain will never cease, afraid I'll go insane.

"I cry out to God, begging for mercy. What have I done to deserve this fate? I feel like an innocent man condemned. I am trapped in a cage of pain, a cage made of rebar. I cannot tolerate it another second. I try a desperate escape by pushing my face through the bars, but I can go no further. I'm trapped in hell."

BACK pain is one of the most common physical complaints, so it's no surprise that treatments for it have multiplied over the years. That ought to be good; instead, many patients find that sudden back pain opens the door to a world of medical confusion.

The effectiveness of virtually every pharmaceutical or surgical remedy, however, has been questioned. And for all the money sufferers spend on doctor visits, hospital stays, procedures and drugs, backs are not improving. The Journal of the American Medical Association reported that spending on back treatments jumped 65 percent to nearly $86 billion from 1997 to 2005, after adjusting for inflation. But during the same period, the proportion of people with reduced function because of spine problems increased, even after controlling for an aging population.

"Low back pain represents so many different diseases that there really hasn't been a breakthrough treatment," said Dr. Russell K. Portenoy, chairman of the department of pain medicine and palliative care at Beth Israel Medical Center in New York. "It's good for the public to know how little we know."

The mystery begins with the first doctor's visit. The exact cause of back pain is never found in 85 percent of patients, said Dr. Dennis C. Turk, professor of anesthesiology and pain research at the University of Washington and a past president of the American Pain Society. Even magnetic resonance imaging seldom sheds light; in many studies the scans have picked up spinal abnormalities in many people who have never reported back pain.

So what's a sufferer to do?

Narcotic pain relievers like OxyContin, used regularly by more than eight million Americans, can help, but doctors remain deeply divided over when to prescribe them. The painkillers can also be highly addictive and lead to mood changes.

"I think we are an overmedicated society, and I would not recommend narcotics for everyday back pain except for in most rare of circumstances," said Dr. James N. Weinstein, editor of the medical journal Spine and chairman of the department of orthopedic surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Alternatives to narcotics have proved problematic, too. Two anti-inflammatory drugs, Vioxx and Bextra, were taken off the market after being linked to heart attacks. And ibuprofen and aspirin can cause gastrointestinal bleeding or organ damage at high doses.

Spinal injections of steroids and anesthetics increased by nearly a third during the 1990s, but several scientific reviews found scant evidence that these provided more than short-term relief. Some doctors have begun prescribing drugs like Lyrica, an anticonvulsant, and Cymbalta, an antidepressant, to treat chronic back pain. But the data on antidepressants is also mixed. A study last fall in The Annals of Internal Medicine found that antidepressants help back sufferers, but this year a review by the respected Cochrane Collaboration, a nonprofit organization for health information, concluded there was no evidence that antidepressants offered relief.

While the quest for a safe and effective pain pill continues, Americans undergo more than 300,000 spinal fusion surgeries a year, at an average cost of $59,000 each, according to the National Center for Health Statistics. Almost as many undergo laminectomies or diskectomies to remove damaged vertebrae and disks.

For some, back surgery can be life-changing, eliminating pain and disability. But for others, it can have serious consequences. One study found that 11.6 percent of patients in the 78 spinal surgeries that were analyzed developed infections and other complications.

Newer procedures, like implants of medication pumps and stimulators, have received mixed reviews, too. The jury is still out on kyphoplasty, an outpatient procedure for patients with vertebrae fracture from osteoporosis. The doctor inserts a needle into the spine and inflates a balloon, then injects a cement, gluing the bones together. The procedure works only for some patients.

With such uncertainties, it is little wonder that many doctors have fallen back on more traditional approaches to easing the pain, like exercise or counseling. This year, the Accreditation Council for Graduate Medical Education began requiring that medical residents who want to become pain specialists study not only anesthesiology but also psychology, neurology and rehabilitative medicine.

The reality is that most people with back pain heal on their own, slowly, without major intervention. "The best treatment for straightforward back pain without a specific diagnosis is reactivating yourself to what you normally do as fast as possible," Dr. Weinstein, the Spine editor, said.

Monday, May 12, 2008

ScienceDaily (May 12, 2008) — Losing a limb can be a traumatic experience and, in some cases, emotional and physical pain can linger for years. To better understand the phenomenon, dubbed "phantom limb syndrome," Université de Montréal graduate student Emma Duerden is inviting amputees to come forward and share their experiences for a major study.

"Our main goal is to better understand why amputees retain the memory of pain after losing a limb," explains Ms. Duerden, who is completing her doctorate in the laboratory of Dr. Gary Duncan at the Université de Montréal's Department of Physiology and the Centre de recherche de l'Institut universitaire de gériatrie de Montréal (CRIUGM).

"People are born with a map of their body in their brain," she continues. "After amputation, the representation of the body part still exists -- as a type of sensory memory. The map of the body becomes distorted and previous research has shown that this 'reorganization' is linked to chronic pain. Our current goal is to study these organizational changes in the brain."

Ms. Duerden and her team will use high-resolution imaging techniques to explore the organization of the sensory maps in the brains of amputees. They will utilize new brain imaging software called real-time fMRI, which allows subjects to view their own brain activity while undergoing a scan.

"We aim to develop techniques to help return amputees' sensory map back to its original formation," says Ms. Duerden. "We believe that patients can be trained to reorganize their internal map by focusing on their brain activity. This reorganization is believed to lead to a decrease in pain."

From IV placement to blood draws to injection of medication, millions of needlesticks are performed on children each year - and for the child, parents and healthcare providers alike, the experience frequently is an unpleasant one.

Although techniques and interventions are available to make the process easier, they often are not employed because of barriers such as lack of awareness, time limitations or availability of supplies.

Recognizing the importance of improving needle pain management in pediatrics, RN VOICE (Registered Nurses for Venipuncture Optimization through Increased Comfort and Education) was established to facilitate solutions.

"There's plenty of information available about the impact of needle pain on children, but there's a huge gap between knowledge and practice," explained Sarah Leahy, BA, RN, RSCN, manager of the Center for Pain Relief at Children's Healthcare of Atlanta and member of the RN VOICE steering committee. "You can give people the knowledge but they still don't actually change their practice; the change has to become institutionalized to really be successful."

To bridge the gap from information to implementation, RN VOICE assembled a community of practitioners - nurses, child life specialists, pharmacists and physicians - from across the nation to promote improved needle pain management strategies. The result is a network of experts and a new resource - ManageIVpain.com - through which healthcare providers can access the tools they need to systemize needle pain management measures in their workplaces.

IASP members Thomas and Heather Hadjistavropoulos and their contributors have developed a handbook with advice for older adults with chronic pain problems. IASP Press has published this new book in soft cover as its first patient-oriented book. We asked Thomas and Heather to describe why the book is such an important resource.

Q: Is pain a natural part of growing old?

Thomas: Although pain accompanies many illnesses that affect older people (such as osteoarthritis or cancer), it is not the result of old age, but a consequence of disease, illness, or injury that needs to be treated or managed. If we think of pain as a natural part of being old, we may be less inclined to treat it effectively. Persistent pain needs to be managed regardless of a person's age.

Q: Do you see self-help strategies becoming more important as the population ages?

Thomas: With the graying of the baby boom and advances in health care, we are seeing a dramatic increase in the proportion of older adults in society. There are many questions about the extent to which the health care system will be able to meet the needs of the changing demographic. While the effective management of pain will require health care system resources in most cases, effective self-management has the potential of reducing health care visits and the associated costs.

Q: What are some common misconceptions that older persons have about their chronic pain?

Thomas: There are many of these. Sometimes people think of pain in old age as being "natural" and something that needs to be endured. Although pain problems are frequent in old age, they are never "natural." They are symptoms of disease or underlying pathology and should be treated. Other examples include views that analgesics and pain killers are the only line of defense against chronic pain, whereas we know that a variety of approaches, including psychological pain management strategies, can also play a key role in managing pain.

Q: What is unique about Pain Management for Older Adults: A Self-Help Guide?

Thomas: While there are several self-help books designed to help people manage their pain and cope with associated stress, not much attention has been paid, within the self-help literature, to the management of pain among older adults. Older adults are different in many respects. Age-related changes in our bodies result in the need for different medication dosages. Recommendations for physical activity programs also are different among older adults. Moreover, the types of stressors that older adults face — such as empty nest syndrome and widowhood — tend to be different from those of younger persons. As such, the type of pain management and related stress management information needs to be tailored to the context of the older adult. This is what we hope we have accomplished with our book. The book brings together many clinical experts, representing the disciplines of medicine, clinical psychology, nursing, exercise therapy, kinesiology, dietetics, and pharmacy with vast combined experience in the medical, psychosocial, and physical management of chronic pain.

Q: What kind of clinical experience does each of you have with older patients?

Thomas: My professional training is in clinical psychology. I began clinical work with older adults approximately 18 years ago. After noticing the high frequency of pain problems among older persons, I became very interested in pain assessment and management among seniors. My clinical work with older persons has focused on assessment and psychosocial pain management (e.g., helping people deal with the psychological consequences of chronic pain) in conjunction with regular medical care.

Heather: My clinical practice is quite diverse. Some of my practice is focused on the psychological assessment of people who suffer from chronic pain. I also provide psychological treatment to individuals who have anxiety disorders, mood disorders, or adjustment disorder in response to a medical condition. I use a cognitive-behavioral approach in my work with clients. My work with older adults typically focuses on facilitating adjustment to chronic medical conditions. This work often involves assisting with development of strategies for dealing with pain, depression, or anxiety. The work can also involve helping clients make general changes in their health habits, such as increasing exercise, eating better, or quitting smoking. At the University of Regina, I started a Psychology Training Clinic a number of years ago. At this time, I am exclusively supervising students who are interested in working with older adults who are anxious about their health. This anxiety about health is often triggered by experiences with pain from a variety of medical conditions.

Q: What are some of the ways you keep readers motivated to progress through the book and to start practicing the self-help techniques?

Thomas: We present the information in a language that lay people can relate to and understand. As much as possible, we avoid scientific jargon. Where appropriate, and always using lay language, the book makes reference to scientific evidence that supports the effectiveness of approaches discussed in the book. We include vignettes to illustrate some of the problems and potential solutions that we discuss in the book, and we encourage readers to move slowly as they practice the coping skills discussed in the book. We also provide recording forms to help people monitor their practice, progress, and successes over time.

Q: Do you have a particular story about a patient who used some of the techniques you present in the book to make dramatic improvements in his or her quality of life?

Heather: One client who really stands out for me is an older man who suffered from chronic low back pain resulting from work injuries and surgeries he underwent in his 40s. When I began to work with him, he was extremely angry because he was in pain and he was at a point in his life where he was "supposed to enjoy life." He was still focused on wanting someone to fix him, and frustrated that no one was willing to operate on him. We used many of the strategies that are discussed in the book. The key to working with him was to ask him to temporarily let go of trying to get someone to operate on him and to start by having him focus on what was in his control and what he could do to improve his pain and life. We worked on changing negative thoughts, incorporating relaxation strategies, scheduling pleasant events, improving his communication with his family, and encouraging a healthy lifestyle. It was the combination of all of the strategies that helped him; no one strategy would have been effective on its own. One thing that was very rewarding about working with this client was that when we started to work together, he was very negative about seeing a psychologist and only came to see me because his wife insisted. As we worked together, however, he really opened up, and now he recommends psychologists to everyone! He no longer even thinks about surgery. He has excellent quality of life, spending time every day exercising, enjoying hobbies, and being with his family.

Q: Why should physicians recommend this book to their older patients?

Thomas: There are very few self-help pain management resources that are specifically tailored for older adults. Most importantly, the book helps foster a sense of control over one's pain, and we know that people who have an enhanced sense of control over their pain have better outcomes. In addition to describing a variety of self-management coping strategies, the book provides useful educational information about topics such as pain management medication, sleep hygiene, and nutrition. Physicians often provide such information to their patients, but time constraints limit the amount of information they can provide. Having such information available in written form can help patients understand the information, while saving time in the medical office.

Thursday, May 01, 2008

Those with lower incomes and less education are in pain more often, researchers say

A novel study that attempts to paint the most accurate and detailed description yet of how Americans experience pain has found that a significant portion of the population -- 28 percent -- are in pain at any given moment and those with less education and lower income spend more of their time in pain. Those in pain are less likely to work or socialize with others and are more inclined to watch television than the pain-free.

The study, which appears in the May 3 issue of The Lancet, was prepared by Alan Krueger, a professor of economics at Princeton University, and Arthur Stone, a professor of psychiatry and behavioral science at Stony Brook University. The work is the first of its type, according to the authors, to quantify a "pain gap" in American society, with the "have-nots" suffering a disproportionate amount in relation to the "haves."

"To a significant extent, pain does divide the classes," said Krueger, the Bendheim Professor in Economics and Public Policy. "And just how the levels of pain vary among people and across activities -- that has never been found before until now."

Participants with less than a high school degree were found to report twice the average pain rating throughout the day as did college graduates. The researchers also found the average pain rating to be twice as high for those in households with annual incomes below $30,000 as for those in households with incomes above $100,000.

"People in households making less than $30,000 a year spend almost 20 percent of their time in moderate to severe pain, compared with less than 8 percent for those in households with income above $100,000 a year," Krueger said.

Pain imposes considerable costs on the health care system and economy. Americans spend billions of dollars each year on painkillers, more than on any other type of medication. And, when workers are suffering, the resulting lost productivity costs business more than $60 billion annually.

Yet, according to Krueger, the phenomenon of pain -- who is in pain and when -- is not well understood.

The authors constructed a new approach in which participants, a representative group of 4,000 Americans, reported their activities and the occurrence and intensity of pain in a diary survey over a 24-hour period. From the data, the researchers could tie the participants' pain to certain activities, demographic characteristics and times of the day. Pain tended to be more frequent when people received medical care or cared for adults.

The researchers did not ask the survey participants to make a distinction between physical and mental pain because all pain, the researchers said, is subjective. Yet clearly, they said, many of the participants were reporting physical pain.

"The novelty of this study is the possibility to relate people's pain experiences to their daily activities," wrote Juha H.O. Turunen, a professor in the Department of Social Pharmacy at the University of Kuopio in Finland, in an accompanying commentary.

The study, Turunen noted, may have broad implications for policymakers. Social programs could be constructed to help those who are in pain while caring for relatives. "The burdensome life of those caring for their loved ones must be supported by society," he wrote. The differing levels of pain recorded by varying income groups, he said, "emphasizes the need for pain preventing measures such as better ergonomics and better availability of occupational health services for jobs with high physical strains."

Workers in blue collar jobs reported higher occurrences and more severe pain than did those in white collar jobs. For blue collar workers, pain was lower when they were off work than when they were working. The 13 percent of people who reported a work-related disability experienced very high rates of pain, and accounted for 44 percent of the total amount of time that Americans spent in moderate to severe pain.

Those in the most pain expressed the least satisfaction with life and health, the authors found. People were more likely to feel pain when they were alone compared with when they were with friends or a spouse. In addition, those in pain spent a disproportionate amount of their time -- almost 25 percent -- watching television, compared with 16 percent for others.

Alarmingly, those in pain were likely to suffer over years, even decades. "The pain doesn't go away in many cases, when people stop working," Krueger said. Pain was higher and more common for older individuals, but the amount of pain reported remained relatively constant for individuals from their mid-40s to their mid-70s.

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The survey, called the Princeton Affect and Time Survey, was designed by the authors and administered by the Gallup Organization in a telephone survey from May through August 2006. The research was funded by the National Institute on Aging and the Hewlett Foundation. The study and underlying data are available at www.krueger.princeton.edu.

The survey is an outgrowth of work Krueger and Stone conducted with Daniel Kahneman, a Nobel laureate and Princeton's Eugene Higgins Professor of Psychology Emeritus, on measuring well-being and time use.